Williston Care Center and Rehab

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received an accurate assessment reflective of the resident status for 2 of 7 residents, Residents #1 and #3 reviewed for Minimum Data Set (MD) assessments. 1)Review of Resident #1 Minimum Data Set (MDS) titled Quarterly dated 9/18/2025 in Section J Bladder and Bowel documented no indwelling catheter. Review of Resident #1 physician order dated 1/24/2025 read, Cath [Catheter] Change urinary catheter bag and tubing once monthly and as needed. Review of Resident #1 physician order dated 9/9/2025 read, Suprapubic Catheter Dx [Diagnosis]: Neurogenic bladder. Review of Resident #1 physician order dated 9/9/2025 read, Cath: Catheter care with soap and water every shift pat dry, apply T-drain per resident request and as needed. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain dignity for a resident who needed assistance with feeding for 1 of 6 residents, Resident #5, reviewed for dining.

Inspectors wroteBased on record reviews and interviews, the facility failed to accurately assess the resident status for 3 of 9 residents, Residents #31, #54, and #367) reviewed for accuracy of assessments.

Inspectors wroteBased on record reviews and interviews, the facility failed to develop and implement a comprehensive person-centered care plan that addressed the residents' medical, physical, mental and psychosocial needs for 4 of 9 residents, Resident numbers #31, #33, #66, and #367, reviewed for comprehensive care plans.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide nail care services for dependent residents for 1 of 5 residents, Resident #54, reviewed for activities of daily living (ADL).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure it is free of medication errors of five percent or greater for 2 of 33 observations of medication administration, the error rate was 6.06%.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with accepted professional principles for 2 of 4 medication carts and 1 of 4 hallways reviewed for unattended medication and labeling.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain complete and accurately documented medical records for 1 of 6 residents, Resident #66 reviewed for medication review and 1 of 3 residents, Resident #31 reviewed for weights.

Inspectors wrote2) During an observation on 3/31/25 at 9:55 AM, Resident #29 was lying in a bariatric bed; dressed in a hospital gown and wearing a brief. Both of the resident's feet were propped up on pillows, and there was a Podus Boot (designed to support and position the ankle and foot) on his right foot. During an interview on 3/31/25 at 9:55 AM, Resident #29 stated that he wore briefs and that he required assistance from the staff for his Activities of Daily Living (ADL) needs. During an observation on 4/2/25 at 9:25 AM, Staff A, Certified Nursing Assistant (CNA) performed peri-care for Resident #29. Staff A did not remove her gloves and perform hand hygiene. Staff A opened a drawer in Resident #29's dresser, pulled out a tube of ointment, and applied some to Resident #29's sacrum and buttocks. [...]

Inspectors wroteBased on observation, interview, and review of facility policy and procedure the facility failed to label and store all medications in accordance with professional standards of practice in 3 of 4 medication carts reviewed for medication storage.

Inspectors wroteBased on record review, interview, and review of policies and procedures the facility failed to consult with the physician and/or resident representative when there was a change of condition for 2 of 4 residents, Residents #47 and #361, reviewed for changes in condition in a total sample of 37 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement a person-centered comprehensive care plan for respiratory care for 2 of 3 residents, Resident #96 and #7, reviewed for respiratory care services out of a total sample of 37 residents.

Inspectors wroteBased on record review, interview, and review of the facility policies and procedures the facility failed to ensure residents who required blood glucose monitoring received treatment in accordance with professional standards of practice by failing to document, assess and treat hypoglycemia (low blood sugar) for 1 of 3 residents, Resident #47, reviewed for insulin administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary care and services for maintaining urine flow and ensuring proper infection control techniques for urinary catheter care for 1 of 3 residents, Resident #361, reviewed for urinary catheters in a total sample of 37 residents.

Inspectors wroteBased on observations, interviews, and policy and procedure review, the facility failed to ensure food items are dated and/or labeled, expired sanitation test strips are discarded, and food is served in accordance with professional standards for food service and safety.

Inspectors wroteBased on resident record review and interview the facility failed to ensure accurate and complete record documentation of insulin administration for 1 of 3 residents, Resident #47, reviewed for insulin administration.

Inspectors wroteBased on observation, interview, and review of facility policies and procedures the facility failed to ensure infection control practice standards were maintained for 1 of 5 observations during medication administration.

Inspectors wroteBased on interviews and record review, the facility failed to honor a resident's expressed advanced directive for end of life by failing to ensure life saving measures, such as cardiopulmonary resuscitation [CPR], were initiated when Resident #1 was found unresponsive and absent of life. Staff A, Licensed Practical Nurse stated the resident was dead and she did not provide cardiopulmonary resuscitation or contact Emergency Medical Services. The resident was not legally pronounced deceased until the Medical Director wrote a clarification statement on [DATE] at 8:27 PM stating that he had acknowledged the resident's death by releasing the remains to a funeral home. The hospice report of death record states the facility staff pronounced the resident deceased and did not document hospice's assessment of the resident's status. [...]

Inspectors wroteThe facility failed to ensure nursing staff followed policy/procedure and the nurse practice act related to initiating emergency care for a resident found to be without a pulse or respiration such as initiating cardiopulmonary resuscitation (CPR) or calling emergency medical services. Staff A, a Licensed Practical Nurse, observed Resident #1 on [DATE] at 6:30 AM, unresponsive and absent of life, pronounced Resident #1 as deceased and withheld cardiopulmonary resuscitation despite the resident's full code status. The Licensed Practical Nurse stated the resident was dead and she did not provide cardiopulmonary resuscitation or contact Emergency Medical Services. The resident was not legally pronounced deceased until the Medical Director wrote a clarification statement on [DATE] at 8:27 PM stating that he had acknowledged the resident's death by releasing the remains to a funeral home. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a complete and accurately documented medical records for 1 of 3 sampled residents, Resident #1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received care for peripherally inserted central catheters in accordance with professional standards of practice for 2 of 2 residents with central venous catheters, Residents #200 and #206, in a total sample of 48 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the food production area and equipment in a clean and sanitary manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received respiratory care and services consistent with professional standards of practice for 2 of 3 residents, Residents #89 and #78, in a total sample of 48 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles and included the expiration date when applicable in 4 of 5 medication carts reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the possible development and transmission of communicable diseases and infections. The facility failed to ensure the staff performed hand hygiene during medication administration in 6 of 8 observations of medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional supplements were offered as ordered by the physician for 1 of 5 residents reviewed for nutrition, Resident #70, in a total sample of 48 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medically-related social services for 1 of 3 residents reviewed, Resident #17, in a total sample of 48 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurately documented for 1 of 6 residents reviewed for unnecessary medications, Resident #80, in a total sample of 48 residents.